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New ACA Guidance Addresses Cost Sharing, Wellness, Mental Health

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Jan. 9 --Beginning in 2015, health plans and issuers are
required to apply all out-of-pocket maximums across all essential benefits, the
federal government said in a new set of frequently-asked-questions and answers on
implementation of the Affordable Care Act.

Because the cost-sharing
limits included in the ACA only apply to essential health benefits, “plans are
not required to apply the annual limitation on out-of-pocket maximums to
benefits that are not” essential health benefits, the departments of Labor,
Treasury and Health and Human Services said in their 18th set of FAQs and
answers on ACA implementation, released Jan. 9.

The agencies also said
in the guidance that plans are able to divide the annual limits on
out-of-pocket costs over multiple categories of benefits.

“Plans and
issuers are permitted to structure a benefit design using separate
out-of-pocket limits, provided that the combined amount of any separate
out-of-pocket limits applicable to all [essential health benefits] under the
plan does not exceed the annual limitation on out-of-pocket maximums for that
year,” the FAQs said.

The FAQs also said that a plan with a provider
network isn't required to count a participant's out-of-pocket expenses for
items and services obtained outside of the plan's network toward the annual
out-of-pocket limits for the plan. Additionally, plans aren't required to count
costs for services that aren't covered by the plan toward the out-of-pocket
maximum for the year, the guidance said.

In addition to cost-sharing
limitations, the FAQs tackle a host of other ACA-related issues, including the
health-care law's impact on the Mental Health Parity and Addiction Equity Act,
wellness programs and the definition of “insured expatriate health plan.”

Wellness Programs

If participants in a group health plan decline
the chance to avoid a “tobacco premium surcharge” by enrolling in a smoking
cessation program at the beginning of a plan year, the plan isn't obligated to
offer the participants the discount if they decide to join the program in the
middle of the year, the guidance said.

“If a participant is provided a
reasonable opportunity to enroll in the tobacco cessation program at the
beginning of the plan year and qualify for the reward (i.e., avoiding the
tobacco premium surcharge) under the program, the plan is not required (but is
permitted) to provide another opportunity to avoid the tobacco premium
surcharge until renewal or reenrollment for coverage for the next plan year,”
the agencies said.

The guidance also addressed the reasonable
alternative standard that plans must provide for participants in
health-contingent wellness programs.

“If an individual's personal
physician states that the outcome-based wellness program is not medically
appropriate for that individual and recommends a weight reduction program (an
activity-only program) instead, the plan must provide a reasonable alternative
standard that accommodates the recommendations of the individual's personal
physician with regard to medical appropriateness. Many different weight
reduction programs may be reasonable for this purpose, and a participant should
discuss different options with the plan,” the guidance said.

Other
Issues

The guidance also explained the impact the ACA had on the
MHPAEA, saying that the ACA “builds on MHPAEA and provides that mental health
and substance use disorder services are one of ten [essential health benefits]
categories.”

The agencies also provided further clarification on the
definition of an insured expatriate health plan, saying it is “an insured group
health plan with respect to which enrollment is limited to primary insureds for
whom there is a good faith expectation that such individuals will reside
outside of their home country or outside of the United States for at least six
months of a 12-month period and any covered dependents, and also with respect
to group health insurance coverage offered in conjunction with the expatriate
group health plan.”

The FAQs said the agencies are considering further
guidance on insured expatriate group health plans but that any guidance
wouldn't be effective for plan years ending on or before Dec. 31, 2016. Insured
expatriate health plans can continue to rely on the temporary relief given in
FAQs issued in March 2013 (31 HRR 259, 3/18/13) through at least 2016, the
guidance said.

In addition, the guidance addressed the coverage of
preventive services in light of recommendations by the U.S. Preventive Services
Task Force, saying that the recommendations regarding medications for reducing
the risk of breast cancer in women must be implemented by non-grandfathered
group health plans for plan or policy years starting Sept. 24, 2014.

To contact the reporter on this story: Kristen Ricaurte Knebel in
Washington at kknebel@bna.com

To contact the editor responsible
for this story: Phil Kushin at pkushin@bna.com

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